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PASE FACILITY REQUEST FORM
Please complete this request form to inquire about utilizing our lab and facility. Our staff will review and contact you for further information and scheduling.
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COMPANY NAME
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Your answer
Main Contact (full name)
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Your answer
EMAIL FOR MAIN CONTACT
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Your answer
DAYTIME PHONE NUMBER
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Your answer
REQUESTED DATE(S)
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Your answer
REQUESTED START & END TIME OF EVENT
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Your answer
REQUESTED SET UP DATE/TIME
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Your answer
PROGRAM TITLE OR DESCRIPTION
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Your answer
PROCEDURES TO BE PERFORMED IN LAB
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Your answer
TOTAL NUMBER ATTENDING (SURGEONS & VENDOR REPS)
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Your answer
SPECIMEN DESCRIPTION DETAILS
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Your answer
NUMBER OF SPECIMENS/WORK STATIONS NEEDED
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Your answer
LAB EQUIPMENT NEEDS (C-arm, video tower, positioning devices, etc)
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Your answer
INSTRUMENTATION SET UP DESCRIPTION (scapels, retractors,etc)
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Your answer
* DRILLS/POWER TOOLS MAY NOT BE AVAILABLE - It is recommended to provide your own if possible.
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Your answer
YES/NO CONFERENCE ROOM NEEDED (small conference room holds up to 30)
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YES
No
PROJECTOR/SCREEN
Other:
YES/NO AUDITORIUM NEEDED (seats 30-400) AV Specialist consultant will be arranged with extra fee)
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NO
YES
If YES, AV Specialist will be contracted in for Additional fees
Other:
Required
ADDITIONAL NOTES/COMMENTS TO SHARE:
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